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Showing results for "adverse events".
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241. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - If these factors can be identified and modified, the chance of similar events can be reduced. … prevention of future adverse events. … The systems approach recognizes that all adverse events have multiple contributing factors, many of … Smith transferred back to 3 North, events unremarkable. March 15, 2014 Mr. … Latent hazard: the hidden problems within health care systems that contribute to adverse events.

242. Final Progress Report: Investigating Failures of Notification and Monitoring in Outpatient Care: the Safety Promotion Action Research and Knowledge Network (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/sarkar2-report.pdf
     January 01, 2024 - Incidence and preventability of adverse drug events in hospitalized adults. … Adverse events in primary care identified from a risk-management database. … National surveillance of emergency department visits for outpatient adverse drug events. … Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes … Adverse Drug Events in U.S. Adult Ambulatory Medical Care. Health Serv R es.

243. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/waever.html
     August 01, 2017 - Studies of claims have shown that the perceived cause, context, outcome, and response to a given adverse … Paid malpractice claims for adverse events in inpatient and outpatient settings. … Exploring relationships between hospital patient safety culture and adverse events. … Health care professionals as second victims after adverse events: a systematic review. … The natural history of recovery for the healthcare provider “second victim” after adverse patient events

244. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - ■ 44% of adverse events were preventable. … ■ Potential decrease in adverse events being litigated, which can potentially lead to lower malpractice … and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events … Slide 16 6 – Facilitator Notes - Grand Rounds Presentation Say: A good response to adverse events … metrics, allowing for clarification and improvement of the CANDOR processes and preventing similar harm events

245. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - These are adverse events most likely caused by an antibiotic that he probably did not need. … This four-step approach is incorporated into the Learning From Antibiotic-Associated Adverse Events form … For example, you can obtain baseline data regarding number of adverse events related to antibiotic use … Then compare this to the number of adverse events after your intervention to determine if the intervention … Use the Learning From Antibiotic-Associated Adverse Events form to develop a plan.

246. Making the Case That Improving Antibiotic Use Is a Patient Safety Issue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-facilitator-guide.pdf
     November 01, 2019 - They can be associated with adverse events, and when administered to patients who do not need them, … Slide 4 Antibiotic-Associated Adverse Events SAY: All antibiotics have the potential to harm … Often, these adverse events occur after a patient is discharged from the hospital. … Antibiotic-associated adverse drug events then were categorized into clinically significant and non-clinically … Approximately 20 percent of hospitalized patients develop antibiotic-associated adverse events.

247. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
     June 01, 2023 - Families as partners in hospital error and adverse event surveillance. … Comparing patient-reported hospital adverse events with medical record review: do patients know something … An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review … Long-term impacts faced by patients and families after harmful healthcare events. … Health care complaints and adverse events as a means of user involvement for quality and safety improvement

248. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     December 01, 2017 - In addition, surgery is linked to half of all hospital adverse events. … Most hospital adverse events are avoidable. … events. … events and other defects. … events.

249. Reforming the Medical Liability System in Massachusetts: Communication, Apology, and Resolution (CARe) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/sands.html
     August 01, 2017 - adverse events and errors. … Its goals are to (1) proactively identify adverse events, (2) differentiate between injuries caused by … The DA&O approach to adverse events initially did not gain momentum as a risk management practice and … events. … When things go wrong: responding to adverse events: a consensus statement of the Harvard Hospitals. 

250. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
     June 02, 2025 - This number is the total raw number of events occurring within your organization for your chosen time … Patients who experience adverse events often tend to have more comorbidities and other risk factors … and thus have accrued more costs even prior to the adverse event. … both costs and risk of the adverse event (e.g., concurrent cancer diagnosis). … In other words, you are measuring the cost of implementation vs. the cost of not stopping these events

251. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
     June 02, 2025 - This number is the total raw number of events occurring within your organization for your chosen time … Patients who experience adverse events often tend to have more comorbidities and other risk factors … and thus have accrued more costs even prior to the adverse event. … Compare the total costs of having an adverse event (Column G, Total Cost) with the anticipated cost … In other words, you are measuring the cost of implementation vs. the cost of not stopping these events

252. Improving Patient Safety in Healthcare | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
     December 01, 2023 - care, where the complexity of the system and the fragility of the patients creates a greater risk for adverse … events. … a 2-year AHRQ grant in 2005 to evaluate an emergency medicine clinical pharmacist program to avoid adverse … drug events in emergency department (ED) patients. … Fairbanks evaluated over 10,000 ED cases for adverse events, and interviewed ED physicians and nurses

253. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - Key words: probabilistic risk assessment, adverse drug events, ambulatory setting 2 Purpose In our … previous study of preventable adverse drug events among 30,000 older adults treated in the ambulatory … setting by a multispecialty group practice over a 1-year period,1 we found a rate of adverse drug events … of 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years … Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

254. Six New Jersey Hospitals Reduce Adverse Events With AHRQ Medication Reconciliation Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ktcquips85.html
     October 01, 2014 - Six New Jersey Hospitals Reduce Adverse Events With AHRQ Medication Reconciliation Toolkit Search … These events were part of a QIO Learning Network established through an AHRQ Knowledge Transfer project

255. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
     January 01, 2024 - Medication safety issues, which encompass both medication errors and adverse drug events, are a predominant … In other chronic disease states, adverse drug events have been clearly established as a major risk factor … Therefore, early recognition of adverse drug events in kidney transplant recipients will likely help … AE type and severity were defined using the Common Terminology Criteria for Adverse Events. … Incidence and impact of adverse drug events contributing to hospital readmissions in kidney transplant

256. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
     January 01, 2024 - year in the US7; 5% experience potential adverse drug events,8 and 70% of these, or 3.8 million events … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review. … The nature of adverse events in hospitalized patients. … Incidence of adverse events and negligence in hospitalized patients. … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review.

257. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
     January 01, 2018 - Safety Tejal Gandhi Handwriting 16 Ways IT Can Improve Safety • Prevent errors and adverse … events • Facilitating a more rapid response after an adverse event has occurred • Tracking and providing … feedback about adverse events Bates, Gawande 2003 Main Strategies for Preventing Errors and AEs

258. Translating Patient Safety Research into Clinical Practice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Relationship between medication errors and adverse drug events. … Systems analysis of adverse drug events. JAMA. 1995 (274):35–43. 9. … Incidence of adverse events and negligence in hospitalized patients. … Top-priority actions for preventing adverse drug events in hospitals. … The clinical pharmacist’s role in preventing adverse drug events.

259. Articulate Word Output (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/primary-prevention-cvd-with-statins.pdf
     June 02, 2025 - Articulate Word Output Primary Prevention of Cardiovascular Disease (CVD) Events with Statins 1 … There is no good reason to use a high- cost brand name statin. 10 Statins: Adverse Effects … The most important adverse effect of statins is myopathy, or muscle pain, which is reported in about … Other hypothesized adverse effects such as memory loss have not been confirmed when they’ve been examined … On the other hand, the adverse effects appear to be relatively independent of CVD risks.

260. Connecting the Dots: Improving Unit Safety Culture to Stop HAI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
     December 01, 2017 - events and patient satisfaction Slide 7 Negative Correlation: HSOPS and Patient Safety Events … 5 Higher HSOPS scores are associated with fewer adverse events, which validates patient safety culture … Beliefs, behaviors reflect organizational ability to learn Associated with adverse events, patient … Exploring relationships between hospital patient safety culture and adverse events. … Leape, L.L. (2002) Reporting adverse events.